Minitransseptal versus left atrial approach to the mitral valve: a comparison of outcomes

Approaches to the mitral valve include left atriotomy (LA) through the interatrial groove and transseptal approach (TS) through the right atrium. Left atriotomy is more commonly used, but TS offers better mitral visualization in difficult cases. While TS has been associated with more atrial arrhythmias, heart block, and difficulty in repair, strong data are lacking.

Retrospective chart review was conducted of 531 consecutive patients undergoing a mitral valve procedure through sternotomy by a single surgeon between 1989 and 2003. Of these, 273 were performed through the standard LA approach and 258 by a "minitransseptal" approach consisting of a 6-cm vertical incision in the interatrial septum without incising the roof of the right or left atria.

Subset analysis of isolated mitral procedures showed no significant differences in cross-clamp time or total bypass time. Although significantly more TS patients required new pacemakers (10.5% TS versus 5.1% LA) or had new junctional rhythm (8.7% TS versus 4.2% LA), TS patients also had more concomitant valve procedures and redo sternotomies. Multivariate analysis showed that the incidence of new pacemakers was linked most strongly with redo procedures, but TS was not an independent predictor of needing a new pacemaker, new junctional rhythm, or new atrial fibrillation.

The minitransseptal approach can provide excellent mitral valve exposure in difficult cases without any significant increase in junctional rhythm, atrial fibrillation, or new pacemaker requirements.